Therapy for Patients Sleep Wake Disorders

Nursing: Therapy for Patients with Sleep-Wake Disorders

Case Introduction

A 31-year-old male has insomnia since he mentioned he has been finding it extremely difficult to fall asleep for the past six months. Recently, the problem had aggravated due to the sudden loss of his fiancé. His history of inability to sleep fast or not being a great sleeper does exist; the problem has now become unbearable. He cannot fall asleep early and even suffers from a lack of sleep during the night.

His sleep patterns affect his work since he started falling asleep the next day. His previous night was deprived of sleep again, which caused problems at his work. He labors as a forklift operator at a local chemical company.

The client also cited that he was on diphenhydramine; however, the medication caused obstacles in his wellbeing the next morning. He even experienced unpleasant conditions due to the previous physician’s prescription of opiate for acute pain management due to an accident after skiing misfortune. The prescribed hydrocodone/apap (acetaminophen) has not been given to him in 4 years for an opiate analgesic. 

The point of concern arises when he mentions that alcohol helps him sleep better. He takes at least four beers before bed each night, which is not a good sign. Sleep cycles are the predictors of good mental and physical health, which, if disturbed once, can cause problems for the rest of life. Sleep initiation and maintenance need to be monitored to prevent adverse patient outcomes, especially in managing chronic diseases (Plescia et al., 2021).

The patient’s alcohol use for sleeping is also an issue since mild amounts of alcohol are a central nervous system relaxant and numb nerves for sometimes, stimulating sleep for several hours (Plescia et al., 2021). However, when the body gets used to it for a longer period, it might get immune to its effects, forcing the patient to take higher quantities that disrupt sleep quality, generating sleep latency, negatively impacting REM (rapid eye movement) and a total time of sleep with memory, learning and sleep-wake instabilities (Plescia et al., 2021). 

Decision 1

The first decision would be to give the patient Zolpidem 5mg. Reducing the potency from 10mg to 5mg would help the patient sleep better. Since 10mg of Zolpidem caused him a “knock out” despite falling asleep better, he could not recall making breakfast in the middle of the night, as recalled by his girlfriend. However, the mentioned medication has memory loss side effects, which could be evident due to the high dose in the form of the patient not remembering to make breakfast (NHS, 2019). 

The other two options present in the exercise were not selected since Zolpidem did initiate positive results regarding his sleep pattern. Discontinuing the medication did not seem appropriate as there were no significant side effects for the prescribed drug. However, initiating therapy to avoid alcohol use could be a great option. Still discontinuing the drug mentioned above did not seem right as the patient confidently mentioned falling asleep right away, which was not the case when he was having trouble falling asleep and then repeatedly waking up during the night. 

It was hoped that sleep patterns would become stable over time after continuous intake of the prescribed medication; Zolpidem is positively impactful for insomnia patients since it does not induce daytime sleepiness, which was previously experienced by the patient under study (Edinoff et al., 2021). The daytime sleepiness was affecting his work behaviors, which is not witnessed with Zolpidem. Zolpidem is also believed to be effective when given side by side with behavioral therapies, which is needed for the patient since alcohol dependency needs to be reduced (Edinoff et al., 2021). However, as the first decision is only chosen for now, for which his sleep has improved, Zolpidem remains a suitable pharmacological treatment for him. 

Ethical considerations that imply prescribing Zolpidem are nonmaleficence (not harming the patient), autonomy as he should have the right to refuse or accept the dosage, and beneficence for his best health outcomes (Peters, 2014). 

Decision 2

The second decision is discontinuing Trazodone and initiating therapy with Suvorexant 10mg daily at bedtime. Suvorexant has shown proven positive results in alleviating insomnia and inducing sleep, especially for treating sleep latency and allowing uninterrupted sleep during the night (Lee-Iannotti & Parish, 2016). The medicine works by decreasing arousals and blocking the orexin-mediated sleeplessness, which is particularly effective in treating primary insomnia. 

The other two options were not selected since Trazodone caused an erection for the patient when he woke up in the morning. It was an embarrassment for him to face his daughter and girlfriend and have coffee or breakfast with them. Initiating therapy along with medication change would help him change behaviors towards alcohol intake before bed. Since the patient is more dependent on alcohol, possibly to relieve the stress that occurred specifically after the death of his fiancé, alcohol addiction needs to be treated with behavioral intervention along with medication. 

It was hoped that better preservation results would be achieved with a change of medication and behavioral therapy since prolonged dependency on alcohol can aggravate sleep disorders in older age (Britton et al., 2020). Short or disturbed sleep during the night predicts the risk for chronic diseases in later stages of life (Britton et al., 2020). The patient might be at risk, especially if he is experiencing stress after his fiancé’s death. Work problems are already experienced, so the relationship between alcohol consumption and sleep disorders causes complications. 

The same ethical considerations apply to this decision since posing no harm to the patient, his maximum health benefit, and independence to choose whether to accept or reject the medication change decision should be in the patient’s best interest (Peters, 2014). It would also include a moral duty of the physician towards his professional designation. 

Decision 3

The third selected decision would be to continue Hydroxyzine 50mg daily before bedtime as the patient mentioned a better sleep cycle with the prescribed drug. However, he experienced the same unpleasant condition as was with the prior medicine. Also, his mouth and eyes are dry, which could be told by the doctor that they are normal side effects and could be treated with simple steps. Having a sipper by the bedside could be helpful as he could take one or two sips during the night whenever his throat feels dry. Again, this could cause problems for waking up frequently during sleep, disturbing his sleep cycle. It is still expected that with medication, he would be sleeping peacefully. 

The other two options were selected since the patient reported positive outcomes of the prescribed drug. No need was felt to reduce the medication dosage or even discontinue it. However, the patient needs to be educated about its side effect. Patient education is imperative in helping the patient avoid developing chronic diseases (Tan, 2020). As mentioned earlier, chronic diseases are likely to progress with age if not prevented at a young age; a serious case is a patient under study who is relying more than before on alcohol consumption for sleep enhancement. Patient education for drug side effects would improve medication adherence so that chronic illness in life stages is decreased with optimal benefits (Tan, 2020).